Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017.

CHAPTER 22.

SOMATIZATION

Introduction

A group of disorders in which the central feature is physical symptoms, for which
sufficient physical cause cannot be found.

[A term for such symptoms – medically unexplained symptoms (MUS)]

These disorders have been known by different names over the centuries.

The DSM-5 (published in 2013) is critical of clinicians who, when dealing with these
disorders, focus on the absence of an adequate physical explanation for the physical
symptoms. Instead, it recommends the focus should be on the fact that these
symptoms are the cause of distress.

The current author considers this change to be a gigantic example of detrimental

political correctness - instigated for fear that the absence of pathology may be taken as
indicating unworthiness (forming a basis for ‘discrimination’). [Recently a leading
scholar opined that focusing on the absence of a physical explanation “…pollutes the
therapeutic relationship by introducing an element of mutual distrust as well as
implicit, if not explicit, blame”. Well, in the hands of a good doctor, it doesn’t.]

Be that as it may, the reader has to live and work with a new classification – which is
detailed in a DSM-5 chapter, titled: Somatic Symptom and Related Disorders. It
deals with:
• Somatoform symptom disorder
• Illness anxiety disorder
• Conversion (functional neurological symptom) disorder
• Factitious disorder

[In Download of Psychiatry, Factitious disorder is further described in the next

chapter, which also deals with malingering.]

These disorders are costly to the community. Patients with them have twice the
number of primary care visits, three times the number of general hospital bed-days
and almost four times as many psychiatric bed-days as controls (Andersen et al,
2013).

Suicidality can be a substantial problem in managing this patient group in the primary
care setting (Wiborg et al, 2013).

An APPENDIX at the end of this chapter may captivate the pathologically interested
reader.
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 2

Somatization – an important concept

Soma (Greek) refers to the body of an organism.

Somatization is a descriptive term (not a diagnosis).

Somatization is defined as the propensity of a patient to experience and report

physical/somatic symptoms that have no pathophysiological explanation, to
misattribute them to disease, and to seek medical attention for them (Lipowski, 1988).

Some elements of this definition - There is a “propensity”, thus particular personality

traits are present (and repeated presentations can be expected from individuals with
this propensity).
The symptoms are “experienced”, not just reported. Thus, somatizing patients are not
feigning (faking) symptoms.
There is no “pathophysiological explanation” to be found in the organ or region in
which such a finding could be expected. However, comorbid psychiatric symptoms
may exist.
The misattribution of symptoms to somatic disease arises out of the belief that disease
is present.
Medical attention is sought, and sought frequently. In addition, a large amount of
attention is sought from relatives, friends, pharmacists and alternative therapists.

Alexithymia, meaning being “without words to describe emotions”, has been

described as an important factor in somatization (Sifneos, 1996). It is proposed that in
the absence of the ability to describe emotions, individuals respond to stressful life
situations in maladaptive ways, and one of these is to express emotional distress as
physical symptoms. Alexithymic individuals focus on facts, details and external
events, and tend to have a limited fantasy life.

Neuropsychological testing has shown that somatization is associated with

information-processing deficits (Shapiro, 1965; Rief & Nanke, 1999).

When a somatising patient presents, the doctor and patient need to communicate
effectively. The doctor must attempt to understand the patient’s “physical” language.
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 3

Somatic Symptom Disorder

The problem of patients presenting with physical complaints for which there is no
satisfactory physical pathology has been with us for thousands of years. In ancient
Greece the condition now known as Somatoform symptom disorder was thought to be
limited to women, and was believed to be caused by the womb (hystera) roaming
around the female body. The condition was known as hysteria until the latter half of
the 20th century.

DSM-5 criteria
A. One or more somatic symptoms that are distressing or result in disruption of daily
life.
B. Excessive thoughts, feelings, or behaviours related to the somatic symptoms as
manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of symptoms
2. Persistently high level of anxiety about health symptoms
3. Excessive time and energy devoted to these symptoms or health concerns.

An example – a persistent cough which cannot be explained on by physical and

special examinations – the patient believes he/she has tuberculosis and cannot be
reassured by the doctor.

Somatic symptom disorder is found in 5-7% of the general population (DSM-5), and
is one of the most common disorders encounter in general practice (Hatcher and
Arroll, 2008).

The female to male ratio of 10:1 (Yates and Dunayevich, 2014)

Early adversity is associated with somatization in adulthood (Maunder et al, 2017;

Porcerelli et al, 2017). This is not surprizing – the personality is shaped in childhood –
good mothering and absence of adversity are essential. Early adversity impairs
personality development, and people with personality difficulties make maladaptive
responses (including somatization) to the challenges of adult life.

Factors including education and culture/sub-culture play a part in somatization.

Intelligence is negatively associated with the number of “functional somatic
symptoms” reported (Kingma et al, 2009). Somatization is more frequent in the lower
socioeconomic classes (Gentry et al, 1974).

Extensive neuroimaging studies have been conducted – but no consistent

findings/conclusions have been possible.

Useful treatments include cognitive behaviour therapy (Tyrer et al, 2014) and
antidepressants (O’Malley et al, 1999) – especially the older, tricyclics.
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 4

Illness Anxiety Disorder

Illness anxiety disorder (which features excessive concern about developing a disease
and imperviousness to medical reassurance) was also known in antiquity. It was
called ‘hypochondria’. It was assumed the patient had pathology under the cartilage
(chondrium) of the front of the chest, and due to this location, it could not be
examined with the fingers (located/found). The term ‘hypochondriac’, now
considered to be impolite, was also used until the second half of the 20th century.

DSM-5 criteria
A. Preoccupation with having or acquiring a serious illness
B. Somatic symptoms are not present, or only mild in intensity
C. There is a high level of anxiety about health, easily alarmed
D. Excessive health related behaviours (checks pulse, attends hospital)
E. Has been present for at least 6 months

An example - a patient has no clear symptoms but believes he/she has cancer and
cannot be reassured by the doctor.

Fear or belief of having a serious disease is common to all the disorders in this chapter
(Newby et al, 2017).

When the belief is unshakable and held with delusional intensity, the diagnosis
Delusional disorder – somatic type, is appropriate (see DOP Chapter 4).

The diagnosis is frequently made in the primary care.

It is noteworthy that Illness anxiety disorder is not listed among the Anxiety disorders
(Olatunji et al, 2009). Similarities with Anxiety disorders - IAD involves intrusive
distressing thoughts, much like OCD, and concern over bodily symptoms, which can
also be found in panic disorder. Also, in both IAD and the anxiety disorders, there is
the seeking of reassurance which is only temporarily effective.

The notion of placing IAD with the Anxiety disorders finds some support in recent
neuroimaging. Groups of patients with 1) hypochondriasis, 2) OCD, and 3) panic
disorder, were compared with healthy controls while performing mental tasks, using
fMRI (Van den Heuvel et al, 2011). Each patient group showed a decreased
recruitment of the precuneus (a part of the superior parietal lobule hidden in the
medial longitudinal fissure, between the two cerebral hemispheres), caudate nucleus,
global pallidus and thalamus compared to healthy controls. And, there were no
statistically significant differences in brain activation between the three patient
groups. Thus, these 3 patient groups share an alteration in frontal-striatal brain regions
during some mental activity.

This is a difficult condition to manage. CBT is a recommended treatment, but with

modest scientific support (Weck et al, 2017). A 4-16-year follow-up of patients
suffering ‘hypochondriasis’ who have received therapeutic doses of SSRIs found that
40% of patients continued to meet diagnostic criteria (Schweitzer et al, 2011). In a
recent study of combined CBT and medication, 50% of patients failed to respond
(Fallon et al, 2017).
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 5

Conversion disorder

Happily, DSM-5 retained the diagnosis of ‘Conversion disorder’ (however, the

diagnostic criteria were altered a little).

DSM-5 criteria
A. One or more symptoms of altered voluntary motor of sensory function.
B. Evidence of incompatibility between the symptom and recognized
neurological or medical conditions.
C. Not explained by another medical or mental disorder
D. Causes significant distress or impairment in function.

Conversion disorder (also termed, functional neurological disorder) involves a loss or

alteration in bodily function which is not caused by a medical disorder. The most
common examples are loss of movement or sensation of a limb; others include
blindness (Gungor and Aiyer, 2017), pseudoseizures, gait abnormalities, mutism, and
movement disorders (Hallett, 2010).

Conversion disorder is more common among women, and onset occurs across the
lifespan.

There are difficulties as current investigative technology has limitations.

The risk of misdiagnosing physical disorders as conversion is ever present. A recent

long-term follow-up study of conversion disorder found 4% of patients had developed
organic disorders which explained their earlier MUS (Stone et al, 2009).

The DOP author recently diagnosed a patient with conversion disorder who was later
found to have a large mediastinal tumour on X-ray. The nervous system had appeared
normal (within the patient’s ability to co-operate), but there was some weight loss,
and carcinomatous neuropathy was the corrected diagnosis.

In the general hospital setting, 20-25% of patients have individual symptoms of

conversion. Some 5% of patients in general hospital meet the criteria for the full
syndrome. The greatest prevalence of full conversion syndrome (up to 20%) is found
in neurology clinics.
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 6

Psychiatric co-morbidity is frequently present, particularly depression (38-50%) and

anxiety (10-16%). Personality disorder and conversion disorder frequently co-occur.

Neuroimaging studies produce a range of findings. Hassa et al (2017) have recentenly

described dysregulation of the emotion processing and motor control circuits.

Functional MRI has been used to examine people with loss of sensation. When
vibration was applied to the sensate limb there was the expected contralateral
somatosensory activation, however, no such activation when the stimulus was applied
to the anaesthetic side (Ghaffar et al, 2006). Vibration on the anaesthetic side
produced activation in the orbitofrontal and cingulate regions.
The emerging theory is that in conversion disorder certain brain areas are able to
override the activation of the motor and sensory cortices. Attention has focused on the
cingulate: possibly, the caudal segment, which is responsible for willed action, can be
deactivated by the pregenual anterior cingulated cortex as it processes information.
Other prefrontal regions a probably also involved. Thus, discrete neural networks
involved in processing emotion and executive control may be able to suppress regions
associated with a range of other functions [motor, sensory, vision].

[Psychogenic (dissociative) amnesia is discussed elsewhere, but the same principle

appears to apply, with activity in the hippocampus (a memory structure) being
suppressed by activation of the frontal regions (which are involved in executive
function and emotion processing).]

Management may include hospitalization, which relieves social and other pressures. It
is important for any hospitalization to be active and brief. Such patients may become
more dependent if placed in a passive role. There is support for cognitive behaviour
therapy in Somatic Symptom and Related Disorders in general (Krocnke, 2007), but
less for conversion than the others. There is some support for the use of
antidepressants and TMS (Schonfeldt-Lecuona et al, 2006). Psychiatric assessment
should continue, and problems should be discussed. Solutions to problems should be
developed with the participation of the patient. A return to physical activity is strongly
urged. It is useful to send the patient to be mobilized in the physiotherapy department.
While there is no significant physical lesion, such assistance allows the patient to
recover and offers a “face-saving” explanation for the recovery.

Conversion disorder received close attention from psychoanalysts. The classical view
is that unconscious conflicts between id drives and the superego are resolved by the
unconscious production of physical symptoms. The relief of the intolerable conflict
was designated the “primary gain”. The subsequent support from others and the
release from responsibilities of daily life was designated “secondary gain”. The term
secondary gain has leached out into broader use, but from the purist perspective, it
should only be used when we are applying psychoanalytic explanations.

The outcome of conversion disorder is variable. Acute onset which is actively treated
usually gives a good outcome, especially if concurrent psychiatric disorder is present,
and responds to treatment. Chronic disorder may involve a wheel-chair existence and
be difficult to assist (Mace & Trimble, 1996).
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 7

Factitious Disorder (and Malingering)

Are covered in Chapter 23

APPENDIX - Related mater ial

Attribution Theory

What individuals believe about their symptoms influences who they consult and how
they manage their symptoms (King, 1983). Individuals have enduring attributional
styles (Garcia-Campayo et al, 1997), such that when a symptom is experienced, it is
likely to be attributed to a physical, psychological or environmental explanation
(Robins and Kirmayer, 1991). Not surprisingly, general practice attendees with
hypochondriacal tendencies have more physical attributions than those with anxiety
disorders (MacLeod et al, 1998). Educational programs designed to modify attribution
style are useful in the management of chronic pain conditions and somatization (Neng
& Weck, 2013). In chronic pain conditions, the patient often attributes the pain to
progressive damage and is therefore reluctant to be active. This leads to disuse
atrophy and unnecessary disability. When the patient attributes the pain to an
abnormal process (inappropriate pain) rather than progressive anatomical destruction,
the scene is set for improved function.

Medical Anthropology

Illness may be defined, anthropologically, as “the human experience of sickness”. The

process begins with personal awareness of a change in body feeling and continues
with the labelling of the sufferer by the sufferer and his/her family as “ill” (Kleinman
et al, 1978). Illness is greatly dependent on cultural beliefs about disease and
discomfort and has been viewed as a “cultural construction” (Wexler, 1974). Illness
may be construed as the patient’s view of clinical reality (patient’s view). Some claim
that medical doctors treat illness poorly, while traditional and alternative therapists,
who listen and give culturally relevant explanations, treat illness well (Stimson,
1994).

Disease has been defined as “abnormalities in the structure and function of body
organs and systems”. This may be construed as the medical view of clinical reality
(medical view). One criticism of modern medicine is that it focuses on the treatment
of disease and ignores the treatment of illness (Engel, 1977).

Common sense suggests a better outcome will be achieved if both illness and disease
are treated. Toward this end, the doctor should seek to fully understand the patient’s
view, explain the medical view and negotiate a shared view (Von Korff et al, 1997).

Abnormal Illness Behaviour

Abnormal illness behaviour (AIB) provides an intellectual framework for a range of

human behaviours (Pilowsky, 1969). It depends on two sociological concepts, 1)
illness behaviour, and 2) the sick role.
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 8

Illness behaviour is defined as, “the ways in which individuals experience, perceive,
evaluate and respond to their own health status” (Mechanic, 1968).

The sick role is conceptualized as bringing obligations and privileges (Parsons, 1964).
The obligations include that the person seeking the role, 1) accepts that the role is
undesirable, 2) co-operates with others to achieve health, and 3) utilizes the services
of those regarded by society as competent in healing. If these obligations are fulfilled,
the individual is granted the following privileges, a) regarded as not being responsible
for his/her condition, b) accepted as someone requiring care, and c) exempted from
normal obligations (such as work).

On these foundations, Pilowsky (1997) defined AIB as, “an inappropriate or

maladaptive mode of experiencing, evaluating or acting in relation to one’s own state
of health, which persists, despite the fact that a doctor (or other recognized social
agent) offered accurate and reasonably lucid information concerning the person’s
health status and the appropriate course of management (if any), with provision of
adequate opportunity for discussion, clarification and negotiation, based on a
thorough examination of all parameters of functioning (physical, psychological and
social) taking into account the individual’s age, educational and sociocultural
background”.

AIB is an important multifaceted thesis. It highlights the connection between social

influences and health and provides a unifying conceptual basis for illness related
behaviour, including but extending beyond the above disorders, to factitious disorder
and malingering. It also extends in another direction, to the denial of illness. It casts
the individual who denies illness and stays at work under the same umbrella as the
individual who pretends illness and goes to the football - with the majority of illness
behaviours lying somewhere between these two extremes.

In addition, AIB gives context for the responsibility of the doctor as the socially
designated controller of sick role privileges; a frequently onerous and unwelcome
duty.

Medicalization

Medicalization describes the tendency of contemporary society to view everyday life

with a medical perspective. In general it places increased responsibilities with health
professionals, authorities and insurers. This process is a feature of society, not of the
individual. The constructs of society influence the options and the course of action
which will be chosen by the individual.

An example of one form of medicalization is the presentation at the general hospital

of people with social problems. Marital disputes not infrequently result in one party
achieving admission to hospital, wrongly diagnosed as suffering a psychiatric
disorder.

Another form is an accompaniment of very sensible, well intentioned public health

endeavours such as those which urge people to take chest pain seriously and to be
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 9

alert for the early signs of diabetes/cancer. In all probability these save lives. Just as
probably, they encourage the public to regard every ache and pain as a warning sign
of disease and an indication for medical examination.

Psychoanalytic model

While the psychoanalytic model contributed greatly to our understanding of the

human condition, it is rarely applied in the current management of the above
disorders.

This model proposes that subjective experiences of childhood give rise to unconscious
“conflicts” between basic drives (usually sexual and aggressive in nature) and the
superego (the learned code or conscience). These conflicts lead to anxiety, depression,
social and sexual inhibitions, difficulties in interpersonal relationships and somatic
symptoms. It is the work of psychoanalysis to bring these conflicts into awareness.
This process enables the patient to change maladaptive patterns of thinking, behaving
and feeling. Psychoanalysis is a unique form of treatment which requires extensive
training.

Biopsychosocial Model

The biopsychosocial model aims to take account of the broad range of influences
(biological, psychological and social – cultural can also be included) which may
coalesce in the formation of a disorder.

Chronic whiplash injury pain following rear-end collisions may be an example. Some
authorities view the whiplash syndrome as culturally constructed (Trimble, 1981). It
is non-existent or almost non-existent in Singapore, Lithuania, Germany and Greece,
and among laboratory volunteers and fair-ground bumper car drivers, but common in
the USA and Australia (Ferrari and Russell, 1999).

In this example, the biological dimension is most probably an acute sprain which
resolves/heals without any significant residual structural damage. At least in the
majority of cases, no convincing, enduring pathology has been demonstrated using
current medical technology. Important psychosocial determinants are present in
cultures which provide “overwhelming information” regarding the potential for
chronic pain following whiplash injury, medical systems which encourage inactivity
and caution, and litigation processes which involve protracted battles with insurance
companies. Patients are led to expect, amplify and attribute symptoms in a chronic
fashion.

Four-dimensional symptom questionnaire (4DSQ)

The 4DSQ is a recent self-report questionnaire (Terluin et al, 2006) which measures
“distress, depression, anxiety and somatization”. Few other instruments attempt to
quantify somatization. This questionnaire is available free of charge for non-
commercial use (EMGO, 2000).
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 10

Synthesis and Summary

Lipowski’s view that some individuals have a propensity to experience and report
somatic symptoms that have no pathophysiological explanation, to misattribute them
to disease, and to seek medical attention has not been disputed in the literature and
can be accepted. The Somatic Symptoms and Related Disorders all have elements of
somatization and currently emerge in a cultural setting in which medicalization is a
prominent feature. Evidence indicates that cognitive processes are etiologically
important. Many of these disorders are associated with information processing
deficits. In Somatic symptom disorder – with predominant pain, learning is an
etiological mechanism, as demonstrated by the importance of secondary gains and the
influence of social models. Fear of pain and movement may be important in the
maintenance of some chronic pain.

Evidence of the importance of cognition in somatisation continues to grow.

Attributional theory advances the reasonable proposition that ambiguous symptoms
will be interpreted in accordance with personal beliefs and experience. Medical
anthropology emphasizes the importance of the beliefs of the individual and the
culture. AIB forms an alternative envelope for these DSM-5 disorders.

It is probable that somatization syndromes arise where there is an unmet need for
closeness with others (Landa et al, 2012).

Management Recommendations

1. The anthropologists inform us there are at least two views of clinical reality (the
patient’s and the medical view) and that the best outcome is achieved when the patient
and doctor can discuss their respective belief systems and come to a shared view of
clinical reality. This approach is recommended.

2. The evidence for information-processing deficits of those presenting with

somatization suggests that information should be presented in an understandable form
and repeated frequently.

3. Present at all times as caring, confident, firm and approachable (within agreed
limits).

4. After appropriate investigation, inform the patient that no further investigations are
indicated, at this time. Investigations are expensive, and when somatization is present,
they are unhelpful. If one investigates a somatically healthy individual long enough
minor “abnormalities” will eventually be detected, which are not clinically significant,
and which are confusing to the clinician and the patient. Also, if one investigates any
patient long enough, eventually something will go wrong, a puncture site will become
infected, the patient will fall off the X-ray table, a nurse will trip over a lead, there
will be an anaphylactic response. Such events greatly complicate care.

5. Limit the number of number of invasive treatments (for similar reasons to 4).
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 11

6. Limit the number of doctors consulted. This is the only way to limit the
investigations and invasive treatments, and number of explanations provided.
Continue to be involved on condition that the patient does not go outside the agreed
team. An interested general practitioner is essential.

7. Limit the time spent with the patient. Do not present this as punitive. Rather,
discuss the fact that the patient’s needs can best be met by regularly scheduled time-
defined appointments. Point out that you are prepared to help, but that this is only
possible if meetings are regularized. Negotiate a sensible protocol to be followed in
the case of crises.

8. The patient has the right to care. Attention may be according to a time schedule, but
should not be contingent on the patient hiding concerns and distress.

9. Limit the amount of medication. Benzodiazepines, stimulants and analgesics should

be strenuously limited. These patients do experience distress and the use of
antidepressants and mood stabilizers have a role. Antipsychotic medication has a
place in highly aroused individuals or where psychosis is observed or suspected.

10. Diagnose and adequately treat comorbid psychiatric disorders. Be alert for
depression and anxiety. Personality disorder will make management more difficult.

11. Conversion disorder is a special case as here there is usually loss of function.
While there is no physical explanatory lesion, treatment with physiotherapy allows the
patient to recover with dignity.

12. Encourage return to normal activities. Encourage hobbies, exercise, education and
cultural pursuits – these will distract the patient from his/her body, stretch and
strengthen the body and assist the return to normal function. Reward attempts at
activities with praise.

13. Educate and involve the family in management.

14. Understand the need to repeat the reassurance, encouragement of activities and
conditions of care (the limits).

References

American Psychiatric Association. Diagnostic and statistical manual of mental

disorders. 4th ed. Washington DC. American Psychiatric Association, 1994.
Andersen N, Eplov L.Andersen J, et al. Health care use by patients with somatoform
disorders: a register-based follow-up study. Psychosomatics 2013; 54:132-141.
Brown R, Lewis-Fernandez R. Culture and conversion disorder: implications for
DSM-5. Psychiatry 2011; 74:187-206.
EMGO. Four-Dimensional Symptom Questionnaire (4DSQ). 2000
(http://www.emgo.nl/researchtools/4dsq.asp).
Engel G. The need for a new medical model: a challenge for biomedicine. Science
1977, 196, 129-136.
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 12

Fallon B, et al. A Randomized Controlled Trial of Medication and Cognitive-

Behavioral Therapy for Hypochondriasis. Am J Psychiatry 2017; 174: 756-764.
Feinstein A. Conversion disorder: advances in our understanding. Canadian Medical
Association Journal 2011; 183:915-920.
Ferrari R and Russell A. Epidemiology of whiplash: an international dilemma. Annals
of the Rheumatic Diseases 1999, 58, 1-5.
Garcia-Campayo J, Larrubia J, Lobo A, Perez-Echeverria M, Campos R. Attribution
in somatizers: stability and relationship to outcome at 1-year follow-up. Acta
Psychiatrica Scandinavica 1997, 95, 433-438.
Gentry W, Shows W, Thomas M. Chronic low back pain: a psychological profile.
Psychosomatics 1974, 15, 174-177.
Ghaffar O, Staines R, Feinstein A. Functional MRI changes in patients with sensory
conversion disorder. Neurology 2006; 67:2036-2038.
Gungor S, Aiyer Rl Postoperative transient blindness after general anaesthesia and
surgery: a case report of conversion disorder. Pain Manag 2017; 7: 377-381.
Hallett M. Physiology of psychogenic movement disorders. Journal of Clinical
Neuroscience 2010; 17:959-965.
Hassa T. Symptom-specific amygdala hyperactivity modulates motor control network
in conversion disorder. Neuroimage Clin 2017; 15:143-150.
Hatcher S, Arroll B. Assessment and management of medically unexplained
symptoms. BMJ 2008; 336: 1124-1128.
King F. Attribution theory and the health belief model. In: Hewstone M, ed.
Attribution theory: social and functional extensions. Basil Blackwell, Oxford, 1983,
170-186.
Kingma E, Tak L, Muisman M, Rosmalen J. Intelligence is negatively associated with
the number of functional somatic symptoms. Journal of Epidemiology and
Community Health 2009. doi: 10.1136/jech.2008.081638.
Kleinman A, Eisenberg L, Good B. Clinical lessons from anthropologic and cross-
cultural research. Annals of Internal Medicine 1978, 88, 251-258.
Krocnke K. Efficacy of treatment of somatoform disorders: a review of randomized
controlled trials. Psychosomatic Medicine 2007; 69:881-888.
Landa A, Bossis A, Boylan L, Wong P. Beyond the unexplained pain: relational
world if patients with somatization syndromes. Journal of Nervous and Mental
Disease 2012; 200:413-422.
Lipowski Z. Somatization: the concept and its clinical applications. American Journal
of Psychiatry 1988, 145, 1358-1368.
Mace C. Trimble M. ten year outcome of conversion disorder. British Journal of
Psychiatry 1996; 169:282-288.
MacLeod A, Haynes C, Sensky T. Attributions about common body sensations: their
associations with hypochondriasis and anxiety. Psychological Medicine 1998, 28,
225-228.
Maunder R, Hunter J, Atkinson L, et al. An attachment-based model of the
relationship between childhood adversity and somatization in children and adults.
Psychosomatic Medicine. 2017; 79: 506-513.
Mechanic D. Medical Sociology. Free Press, New York, 1968.
Neng J, Weck F. Attribution of somatic symptoms in hypochondriasis. Clin Psychol
Psychother 2013; Oct 9 [Epub ahead of print].
Newby J, et al. DSM-5 illness anxiety disorder and somatic symptom disorder:
comorbidity, correlates, and overlap with DSM-IV hypochondriasis. Journal of
Psychosomatic Research 2017; 101: 31-7.
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 13

O’Malley P et al. Antidepressant therapy for unexplained symptoms and symptom

syndromes. J Fam Pract 1999; 42: 980-990.
Olatunji B, Deacon B, Abramowitz J. Is hypochondriasis an anxiety disorder? British
Journal of Psychiatry 2009; 194: 481-482.
Parsons T. Social Structure and Personality. Collier-Macmillan: London, 1964.
Pilowsky I. Abnormal Illness Behaviour. John Wiley & Sons Ltd. Chichester, 1997.
Pilowsky I. Abnormal illness behaviour. British Journal of Medical Psychology 1969,
42, 347-351.
Porcerelli J, et al. Childhood abuse in adults in primary care: empirical findings and
clinical implications. Int J Psychiatry Med 2017; 52: 265-276.
Rief W, Nanke A. Somatization disorder from a cognitive-psychobiological
perspective. Current Opinion in Psychiatry 1999, 12, 733-738.
Robins J, Kirmayer L. Attributions of common somatic symptoms. Psychological
Medicine 1991, 21, 1029-1045.
Schonfeldt-Lecuona C, Conneman B, Viviani R, et al. Transcranial magnetic
stimulation in motor conversion disorder: a short case series. Journal of Clinical
Neurophysiology 2006; 23:472-475.
Schweitzer P, Zafare U, Pavlicova M, Fallon B. Long-term follow-up of
hypochondriasis after selective serotonin reuptake treatment. Journal of Clinical
Psychopharmacology 2011; 31: 365-368.
Shapiro D. Neurotic Styles. New York. Basic Books. 1965.
Sifneos P. Alexithymia: past and present. American Journal of Psychiatry 1996, 153
(7 Suppl), 137-142.
Stimson G. Obeying the doctor’s orders. Social Science Medicine 1974, 8, 97-104.
Terluin B, van Marwijk H, Ader H, de Vet H, Penninx B, Hermens M, van Boeijen C,
van Balkom J, van der Klink J, Stalman W. The Four-Dimensional Symptom
Questionnaire (4DSQ): a validation study of a multidimensional self-report
questionnaire to assess distress, depression, anxiety and somatization. BMC
Psychiatry 2006: http://www.biomedcentral.com/1471-244X/6/34.
Tyrer P, et al. Clinical and cost-effectiveness of cognitive behaviour therapy for
health anxiety. Lancet 2014; 383(9913): 219-225.
Stone J, Carson A, Duncan R, et al. Symptoms ‘unexplained by organic disease’ in
1114 new neurology out-patients: how often does the diagnosis change at follow-up?
Brain 2009; 132:2878-2888.
Trimble M. Post-traumatic neurosis: form railway spine to the whiplash. Wiley,
Chichester, 1981.
Van den Heuvel A, Mataix-Cols D, Zwitser G, et al. Common limbic and frontal-
striatal disturbances in patients with obsessive compulsive disorder, panic disorder
and hypochondriasis. Psychological Medicine 2011; 41: 2399-2341.
Von Korff M, Gruman J, Schaefer J, Curray S, Wagner E. Collaborative management
of chronic illness. Annals of Internal Medicine 1997, 127, 1097-1102.
Wexler N. Culture and mental illness: a social labelling perspective. Journal of
Nervous and Mental Diseases 1974, 159, 379-395.
Weck F, et al. Cognitive therapy and exposure therapy for hypochondriasis (health
anxiety): A 3-year naturalistic follow-up. J Consult Clin Psychol 2017; 85: 1012-
1017.
Wiborg J, Gieseler D, Fabisch A et al. Suicidality in primary care patients with
somatoform disorders. Psychosom Med 2013; 75: 800-806.
Pridmore S. Download of Psychiatry, Chapter 22. Last modified: November, 2017. 14

Yates W, Dunayevich E. Somatic symptom disorders.

https://emedicine.medscape.com/article/294908-overview. 2014. Accessed,
November 2017.